Building Strength for Life and Love™

Informed Consent for Treatment (Individuals)

Informed Consent for Treatment (Individuals)

Please read and fill out this Informed Consent for Treatment prior to our first session.

Step 1 of 3 - Page 1

  • This form is to authorize, request, give permission for, and consent to psychotherapy services from the practice of Grace McDonald, M.A., Registered Marriage & Family Therapist (RMFT) and Registered Clinical Counsellor (RCC). I understand that our relationship is strictly voluntary and that I may choose to terminate therapy at any time. I understand that my therapist may choose to terminate therapy if he or she determines that continued therapy with him or her will not be beneficial to me. In such a case, I understand that the therapist will explain the reasons for his or her decision. He or she will offer me appropriate referrals or referral sources to continue therapy if I wish, and aid as is appropriate in the transition.

    The frequency and type of treatment will be decided between my therapist and me.

    I understand that the purpose of these procedures will be explained to me and be subject to my verbal agreement.

    I understand that there is an expectation that I (or the minor, I am authorizing therapy for) will benefit from psychotherapy but there's no guarantee that this will occur.

    I understand that the maximum benefit will occur with consistent attendance and that at times, I may feel conflicted about the therapy, as the process can sometimes be uncomfortable.

    I understand that the therapy is confidential aside from exceptions to confidentiality as stated in the law. I understand that the therapist is allowed or required to breach confidentiality by contacting appropriate persons and/or by reporting to the appropriate authorities reasonable suspicion if he/she believes that a child, elderly or disabled person is being abused, including by neglect, assault, battery, or sexual molestation; or if there is a threat of serious harm to myself or another person.

  • By signing below, I acknowledge that I have received, reviewed, and fully understand the terms and conditions of the Agreement for Service for the practice of Grace McDonald, M.A. I have discussed such terms and conditions with the therapist, and have had any questions with regard to its terms and conditions answered to my satisfaction. I agree to abide by the terms and conditions of this Agreement and consent to participate in psychotherapy with the therapist. Moreover, I agree to hold the therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment. If I am signing to consent for treatment for a minor client, I acknowledge that I have the legal right to authorize such treatment. With my signature, I confirm that I have read and fully understand this consent for treatment form.